title: Subarachnoid-pleural fistula treated with noninvasive positive pressure ventilation: a two-case report and literature review.
abstract: METHODS
  A report on 2 cases of subarachnoid pleural fistula (SAPF) treated with noninvasive positive pressure ventilation (NPPV).
  
  
  OBJECTIVE
  To highlight the efficacy of NPPV in patients with SAPF.
  
  
  BACKGROUND
  SAPF is a rare but distressing type of cerebrospinal fluid leakage. It is known to be a complication of anterior thoracic spine surgery. The pressure gradient between the subarachnoid space and the pleural cavity maintains the cerebrospinal fluid leakage and precludes the spontaneous closure of the dura. Surgical interventions such as primary repair, patch grafts, muscle flaps, and omental flaps have been advocated. Only limited reports were found with reference to NPPV applied to SAPF.
  
  
  METHODS
  Two patients, a 45-year-old woman and a 39-year-old woman, underwent anterior thoracic spine surgery to treat thoracic myelopathy caused by ossification of the posterior longitudinal ligament. After surgery, they developed SAPF due to perforation of the dura during surgery. Placement of thoracostomy tubes and subarachnoid drains had no effect and an NPPV device was applied.
  
  
  RESULTS
  During application of the NPPV device, 14 days in the first patient and 5 days in the second patient, the raised intrapleural pressure obstructed the fluid leakage and successfully treated the fistula. No recurrence of SAPF was observed after removal of the NPPV device and the patients avoided surgical interventions.
  
  
  CONCLUSIONS
  SAPF is often resistant to conservative therapies and has been treated in an invasive manner. NPPV should be considered as an alternative before such interventions because it is effective, noninvasive, and safe.
authors.affiliation: Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan. ykurata@h5.dion.ne.jp
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Kurata
authors.forename: Mitsunori
authors.initials: M
authors.lastname: Yoshimoto
authors.forename: Tsuneo
authors.initials: T
authors.lastname: Takebayashi
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kawaguchi
authors.forename: Toshihiko
authors.initials: T
authors.lastname: Yamashita
mesh_terms: D000328:Adult; D065634:Cerebrospinal Fluid Leak; D002559:Cerebrospinal Fluid Rhinorrhea / Q000209:etiology / Q000628:therapy*; D005260:Female; D005402:Fistula / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008875:Middle Aged; D035422:Pleural Cavity / Q000503:physiopathology*; D011175:Positive-Pressure Respiration / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy*; D013346:Subarachnoid Space / Q000503:physiopathology*